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Understanding the Alphabet Soup By: Cheryl Puetz

Transcript of Understanding the Alphabet Soupproaction-ins.com/wp-content/uploads/2014/06/... · 2014. 6. 24. ·...

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Understanding the

Alphabet Soup By: Cheryl Puetz

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Definitions

� ACO � MCO � IPA � Bundle Payments � Dual Eligible

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ACO Accountable Care Organization

�  ACO’s are groups of physicians, hospitals and other health care providers, who come together to give coordinated high quality care to their Medicare patients. By doing so, they will be eligible to share in the savings to generate a relative benchmark.

�  The payment will include covered services beginning 3 days before a hospital admission and extending to 30 days after the hospital discharge on selected procedures.

�  ONLY awarded by CMS

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ACO’s in California �  Accountable Care Clinical

Services, PC �  Affiliated Physicians IPA �  Akira Health, Inc.  �  APCN-ACO �  Cedars-Sinai Accountable Care �  Meritage ACO, LLC �  National ACO �  San Diego Independent ACO �  UCLA Faculty Practice Group �  ApolloMed Accountable Care

Organization Inc. �  Golden Life Healthcare, LLC �  John Muir Physician Network

�  Meridian Holdings, Inc. �  North Coast Medical ACO, Inc. �  Torrance memorial Integrated

Physicians, LLC �  Brown & Toland Physicians �  Heritage California ACO �  Healthcare Partners Medical

Group �  Monarch Healthcare �  Primecare Medical Network �  Sharp Healthcare System �  Primary Partners, LLC �  AppleCare Medical ACO, LLC �  Premier ACO Physicians Network

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MCO Managed Care Organization

� PPO, HMO, POS, EPO, HDHP � Other wise know as commercial insurance

�  Kaiser Permanente �  Blue Cross/Blue Shield �  United Healthcare �  Aetna �  Cigna �  Humana �  and many others

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IPA Independent Physician

Association (the last GREAT FRONTIER)

�  IPA is a legal entity that is organized and directed by physicians (private practice) to negotiate contracts with insurance companies.

�  They have privileges at hospitals but run independently.

�  They have their own case management and do their own billing.

�  Many are trying to find a way to practice quality medicine in spite of the hospitals dictating mandates.

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Bundled Payments for Care Improvement

�  Federal programs to reduce cost and increase higher quality outcomes.

� 48 Categories of Disease states; especially for Cardiac, Respiratory, Diabetes, & GI

� Currently testing the waving of 3 night inpatient stay in hospital. Utilizing Skilled Nursing Facilities and Home Health.

http://innovation.cms.gov/initiatives/bundled-payments/

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Dual Eligibles Medicare-Medical Recipients

Cal MediConnect � Goal is to improve coordination of care � Forced HMO � Complete evaluation of each case

upon enrollment. � Case Manager oversight for highest

utilization of service.

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Cal MediConnect Plans by County Alameda County

Los Angeles County

Orange County

San Diego County

Alameda Alliance for Health

L.A. Care CalOptima* Care 1st

Anthem Blue Cross CareMore Community Health Group

Care1st Health Net

Molina HealthCare

Molina Health Care

Health Net

San Mateo County Riverside County San Bernardino County

Santa Clara County

CareAdvantage Inland Empire Health Plan

Inland Empire Health Plan

Anthem Blue Cross

Molina Health Care

Molina Health Care

Santa Clara Family Health Plan

*Participation pending readiness review.

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MSSP

Start Date

Medicare FFS and in Medi-Cal Managed

Care (enrolled in one month)

Medicare FFS and Medi-Cal FFS (enrolled

by birth month)2

MSSP Benes eligible for Cal Medi-Connect

(enrolled in one month)

CMC DSNP / Part D

LIS Benes (enrolled

in one month)

Opt out of CMC and in

Medi-Cal FFS (enrolled by birth month)

Excluded from CMC

(ESRD, 1915c waiver, etc.) and in Medi-

Cal FFS (enrolled by birth month)

Full Duals in a CMC plan

DSNP/ any LIS reassignees in Medi-Cal FFS (enrolled in one month)

In a non CMC DSNP plan or any MA plan

sponsored by any health plan

(enrolled by birth month)4

Full Duals in Medi-Cal

managed care plan ( benefit added in one

month)1

Excluded from CMC (ESRD,

1915c waiver, etc.) and in

Medi-Cal Managed Care (benefit added in one month)1

MA benes or LIS reassignees in

Medi-Cal Managed Care (benefit added in one month)1

MSSP Beneficiaries in

Medi-Cal managed care

or Medi-Cal FFS (enrolled in one

month)

Medi-Cal Managed Care (benefit added in one month)

Medi-Cal FFS (enrolled by

birth month)2

4/14 San Mateo San Mateo

Los Angeles, Riverside, San

Bernardino, San Diego, and San

Mateo

Los Angeles, Riverside, San

Bernardino, San Diego, and San

Mateo

Los Angeles, Riverside, San

Bernardino, San Diego, and San

Mateo.

San Mateo (Full Duals in MA plan or excluded from

CMC )

5/14Riverside, San Bernardino,

and San Diego

Riverside, San Bernardino,

and San Diego3

Riverside, San Bernardino,

and San Diego

7/14 Los Angeles Los Angeles Los Angeles Santa Clara Santa Clara Santa ClaraSan Mateo

(Partials and Medi-Cal only)

Los Angeles, Riverside, San

Bernardino, San Diego, San

Mateo, and Santa Clara

8/14

Los Angeles, Riverside, San

Bernardino, San Diego, and Santa Clara

Los Angeles, Riverside, San

Bernardino, San Diego, and Santa

Clara

10/14

Los Angeles, Riverside, San Bernardino,

and San Diego

Los Angeles, Riverside, San

Bernardino, San Diego, and Santa

Clara

Los Angeles, Riverside, San

Bernardino, San Diego, and Santa

Clara

1/15Santa Clara,

Alameda, and Orange

Santa Clara and Alameda

Alameda, Santa Clara and Orange

All Eight Counties

Alameda and Santa Clara

AlamedaAll Eight Counties

Alameda Alameda and

Orange Alameda and

OrangeAlameda and

OrangeAlameda and

OrangeAlameda and

OrangeAlameda

4. Those with Aug-Oct birthdays will be enrolled Oct 2014. Nov-July birthdays will be by birth month. There are no FFS Medi-Cal enrollees in Orange and San Mateo counties.

CCI Enrollment Timeline by County and Population** Revised 6.6.14 pending DHCS proposed DSNP/MA policy**

Cal MediConnect enrollment begins in April 2014 with passive enrollment in San Mateo; and "opt-in" in Riverside, San Bernardino, San Diego and Los Angeles counties.

3. Enrollees with April and May birthdays will be enrolled in May 2014. Then follow enrollment schedule by birth month.

1. Enrollees already in a Medi-Cal managed Care plan will receive one notice prior to the change in benefit.2. There are no FFS Medi-Cal Enrollees in Orange and San Mateo counties.

MLTSS (Mandatory enrollment)Cal MediConnect (Passive enrollment)Full Duals in Medi-Cal Managed Care Partial Duals/Medi-Cal onlyFull Duals Only Full Duals in Medi-Cal FFS2

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Company Analysis

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How well do you STACK UP? � Medicare Compare

�  http://www.medicare.gov/homehealthcompare/search.html

� Patient Satisfaction Surveys � Outcome Data (Quality Measures) � Clinical and Therapy Protocols � Utilization Patterns � ER Utilization � Hospital Readmissions

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What You Need…

� Outcome Data (Quality Measures) � Clinical and Therapy Protocols � Utilization Patterns � ER Utilization � Hospital Readmissions by Disease

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Are You Ready for Change? �  Honest independent analysis of your agency �  SWOT analysis �  Do you have the right people?

�  The staff you have today may not be the right staff for tomorrow.

�  Train and Re-train staff �  Are you really ready to make the hard

decisions and stick by them? �  Are your clinicians capable of achieving the

company goals? �  Are you top heavy in management?

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Meeting Preparations

� How can you SAVE them MONEY & IMPROVE their outcomes.

� References (The Right Ones)

� Proof, Proof, Proof

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Meeting with the RIGHT PEOPLE

� CFO � VP of Utilization Management � VP or Director of Case

Management

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Tools � Therapy Utilization � Efficiency + Effectiveness = higher profitability � Sound Protocols/Clinical Pathways � Quality Measurement Programs � ER Prevention Program � Patient Retention Program � Return on Investment

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In Today’s connected world of healthcare, you’re right to be concerned about HIPAA compliance. We are your partner in safeguarding healthcare information and to ensure the confidentiality and integrity of PHI (Protected Health Infor-mation). Stricter HIPAA audits are on the horizon.

THE RULE Unsecured PHI means PHI that is not secured through: encryption: and/or de-struction - as provided by HHS guidance. Methods must render PHI “unusable, unreadable, or indecipherable” to unauthorized individuals (see HIPAA Security Rule & NIST standards).

WHAT YOU SHOULD KNOW Policies without processes are nothing more than empty promises and will not prevent serious compliance liability. HHS is going to want to see evidence not only of policies but processes as well.

POLICIES + PROCESSES + TRACKING = VDE (VISIBLE DEMONSTRATIVE EVIDENCE) Given the lax enforcement of HIPAA’s Privacy & Security Rules prior to the HITECH Act, we are certain that HHS is going to have no problem finding instances of “willful neglect” – especially for those unlucky few to be the first ones audited. You need a technology partner that has a roadmap to help you navigate this maze and establish a culture of compliance in the company that you work hard to grow. Hippo Safe has the most comprehensive solution for you.

H PAA COMPLIANCE

HippoSafe your HIPAA/HITECH technology compliance partner. Call us for a FREE consultation 630.560.4888

www.hipposafe.co

Dermatology practice hit with $150,000 HIPAA fine

(American Academy of Dermatology, January 31, 2014)

Concentra Health Services has agreed to pay $1,725,220 after an unencrypted laptop was stolen from

one of its facilities. http://www.fiercehealthit.com/story/ocr-levies-2-million-hipaa-fines-stolen-

How much can you afford to lose?

Group slapped with $6.8 Million HIPAA FINE

(Healthcare IT News , February 18, 2014)

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In today’s world of healthcare, you’re right to be concerned about your companies survival. We are your partner in weathering the storm.

We analyze and streamline business development, administrative, and clinical processes utilizing available technology resulting in a more effi-cient workflow thus improving:

Speed and accuracy of data Increased patient capacity without the need of additional personnel Better compliance Better quality of care Increased revenue Scalability Proven marketing plan for sustained growth

HippoSafe your guide to surviving the ACA. Call us for a FREE consultation 630.560.4888

HIPAA/HITECH Utilization Management Coding/Oasis/QA Compliance

Quality Improvement Profitability Analysis Business Development Audits Mock Survey www.hipposafe.co

Consulting Services

ACO, Bundled Payments, Utilization Management, QA & Coding

Record Net Income Loses

for the Biggest Home

Health Care Companies CMS continues to cut

Reimbursement

The Storm is Coming… How will your Home Health Survive?